{clni_form}
<script type="text/javascript">
{literal}
function toggleSource(id) {
        if (id.checked == false) {
                document.getElementById('immunization_source').disabled = false;
        }
        else {
                document.getElementById('immunization_source').disabled = true;
        }

        return false;
}
{/literal}
</script>
<table>
<tr>
<td>
Immunization:<br>
{input type="select" name="immunization_name" enumeration="immunizations"}
</td>
</tr>
<tr>
<td>
Immunization Date:<br>
{input name="immunization_date" type="date"}
</td>
</tr>
<tr>
<td>
Lot #:<br>
{input size="50" name="immunization_lot_num" type="string" size="10"}
</td>
</tr>
<tr>
<td>
Reaction:<br>
{input size="50" name="immunization_reaction" type="string"}
</td>
</tr>
<tr>

        <td>Patient Reported: {input type="checkbox" name="immunization_patient_reported" onclick="toggleSource(this);"}</td>
      </tr>
 <tr>
	<td>Source:
        {if $data->_int_storage->_values.immunization_patient_reported eq 1}
        {assign var=disabled value=true}
        {/if}
        {clni_building_list id="immunization_source" name="immunization_source" blank="true" disabled=$disabled }</td>

      </tr>
<tr>
<td>
<br />
{submit}
</td>
</tr>
</table>
